Free E:\SF 2800\SF2800(04-06).vp - Federal

Application for Death Benefits
Civil Service
Retirement System
Civil Service Retirement System
This application is for use by persons applying for benefits which may be payable under the Civil Service Retirement System (CSRS) because of the death of an employee, former employee, or retiree who was covered by CSRS at the time of his/her death or separation from Federal service. You should have received an informational pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System" SF 2800-1, with this application. If you did not receive the pamphlet and the deceased was a Federal employee at the time of his/her death, you should get a copy from the deceased's employing agency. If the deceased was retired or a former employee not yet receiving a retirement benefit, you should get a copy from the Office of Personnel M

This application is for use by persons applying for benefits which may be payable under the Civil Service Retirement System (CSRS) because of the death of an employee, former employee, or retiree who was covered by CSRS at the time of his/her death or separation from Federal service. You should have received an informational pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System" SF 2800-1, with this application. If you did not receive the pamphlet and the deceased was a Federal employee at the time of his/her death, you should get a copy from the deceased's employing agency. If the deceased was retired or a former employee not yet receiving a retirement benefit, you should get a copy from the Office of Personnel Management (OPM). You can write to the Office of Personnel Management at OPM, P.O. Box 45, Boyers, PA 16017-0045, call OPM's Retirement Information Office at 1-888-767-6738, or send us email at [email protected] Within local calling distance to Washington, DC, please dial 202-606-0500. If the deceased was an employee at the time of death, send your completed application, with any attachments, to the personnel office in the agency where the deceased was last employed. If the deceased was a former employee or annuitant at the time of death, send it to the Office of Personnel Management, P.O. Box 45, Boyers, PA 16017-0045. If your address changes before we give you a survivor annuity claim number, notify us in writing and give your name, date of birth, your Social Security Number, and the deceased person's name, date of birth and Social Security Number. If you have received your claim number, notify us of the change by calling or writing as described above. Be sure to refer to your claim number.

Instructions For Completing Application
Type or print clearly in ink. If you need more space in any section, use a plain piece of paper with your name, date of birth, and Social Security Number, and the deceased person's name, date of birth and Social Security Number, written at the top. If you do not know an answer, write "unknown." If you are unsure of information (for example, if you do not know an exact date), answer to the best of your ability, followed by a question mark (?). The following additional information should help you to answer those questions on the application which are not entirely self-explanatory.

Section B - Information About the Applicant
5. If you checked "designated beneficiary" and have a copy of the form designating you as beneficiary, attach it to the application. If you checked "parent," both parents must submit completed applications. If one is deceased, attach a copy of the death certificate. Otherwise, provide name and address of other parent in Section F, if known. If you checked "executor or administrator of estate," attach a copy of the court order appointing you executor or administrator. (Note that a court must have appointed you; we will not pay you based on a will or other document prepared by the deceased.)

Section A - Information About the Deceased
6. 6. 7. If deceased had ever applied for or received retirement benefits, show the retirement claim number. Recurring payments from the Office of Workers' Compensation Programs, U.S. Department of Labor (OWCP) and CSRS survivor annuity benefits usually are not payable for the same period of time. If the deceased had applied for or received benefits from the OWCP based on an illness or injury received resulting from a
condition of employment within the last two years,
indicate here. The OWCP claim number appears on the
U.S. Treasury checks and correspondence from OWCP. See the pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System" to help you determine which block to check.

Section C - Information About the Deceased Person's Spouse
1. Attach a copy of your marriage certificate. If you were married by a priest, rabbi, pastor, Justice of the Peace or other person empowered by the State to perform marriages, check "Clergy/Justice of the Peace". If you were not married by someone empowered by the State to perform marriages, check "Other" and explain (for example, "common law" or "tribal marriage"). If marriage is common law and a State court has determined that you were married, send a copy of the court order or judgment. If you do not have a court order or judgment, attach two notarized affidavits from persons who are in a position to know the facts and clearly state: (1) the relationship between you, your spouse, and the person swearing to the affidavit; (2) the length of time you and the deceased lived together; (3) the address or addresses at which you resided while you lived together; (4) whether there was any public announcement in connection with your common law marriage; (5) whether you and the deceased were regarded among your neighbors, friends, and relatives as being husband and wife during

8.

10. If the deceased had no former marriage, write "none." Attach copies of death certificates and complete copies of court orders of divorce or annulment if these occurred on or after May 7, 1985. If you are the spouse of the deceased and you and the deceased were married more than one time, be sure to show the date your prior marriage(s) ended.
Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices

Previous editions are not usable.

Standard Form 2800 Revised June 2006

the time you lived together; and (6) how the person swearing to the affidavit is in a position to know the facts being presented in the affidavit. In addition, your own affidavit is required. It should state: (1) the date on which, and the State in which, you and your spouse mutually agreed to become husband and wife; (2) whether you or your spouse were ever married, ceremonially or under common law, to anyone else before entering into the common law relationship (if so, state in your affidavit all the facts of each previous marriage, including the date it took place and the date of the death or divorce that ended it); and (3) any other facts you believe will help prove you were husband and wife. You may also submit other documents which show a husband and wife relationship such as a naturalization certificate, deeds, immigration records, insurance policies, passports, child's birth certificate, income tax returns, etc. 2. If you married the deceased more than once, give dates that each marriage began and ended.

2.

The mother of the unborn child, the legal guardian or the person responsible for the child should send us the birth certificate, when available.

3. d.If the person(s) in 3b. is(are) court appointed, indicate by checking the "Legal Guardian" box. If you are the person who is court appointed, attach a copy of the court appointment to this application. If there is no court appointment, check "Other" and write in the relationship to the child, for example, mother, father, sister, etc.

Section F - Information About Other Heirs
Please give us information about other relatives who may be able to inherit from the deceased. If you can't give complete information, do the best you can. List only people who were living when the deceased died and who have the following relationships to the deceased:

· Widow(er) (unless named in Section C); · Children of the deceased not included in Section E
and the children of any deceased children (on a separate sheet of paper, show the relationships of descendants of deceased children to the deceased, for example, John and Mary, children of deceased son John, and Sue, child of deceased daughter Ann);

Section E - Information About the Deceased Person's Dependent Children
1. a. List, in order of birth date, all the surviving, unmarried, dependent children of the deceased. List all such children you know of, no matter where they live. A dependent child is a son or daughter who is unmarried and:

· If there is no living widow(er) or child, list the
deceased person's parents (if only one parent survives, a copy of the deceased parent's death certificate should be attached, if available);

· was under age 18 at the time of the deceased person's
death, including any: 1. 2. 3. adopted child, and/or stepchild, and/or recognized child born out-of-wedlock who lived with the deceased in a regular parent-child relationship, and/or recognized child born out-of-wedlock if there was a judicial determination of support or if the deceased made regular and substantial contributions for the support of the child.

· If there are no living relatives of the deceased as
described above and no court-appointed executor or administrator as described in Section G, list other relatives who can inherit from the deceased. The people you list must be blood kin of the deceased.

4.

Section G - Information About the Deceased Person's Estate
1. If someone was named as executor or administrator in the deceased person's will, but is not appointed by a court, check "no." If you have been appointed by a court, attach a copy of the court appointment.

· is age 18 or older, but who became mentally and/or
physically disabled before age 18 and who, because of the disability, is incapable of self-support.

· is between ages 18 and 22, unmarried, and a full-time
student in a recognized educational institution. b. Attach a copy of the birth certificate for each child for whom you are applying. d. Show how each child is related to the deceased. For example, write "Child of marriage at death" for a child of the deceased person's marriage in force at the time of death. e. If the unmarried dependent son or daughter is 18 or over, state whether he or she is a full-time student and/or disabled. Adult children may submit separate applications if they want separate payments made to them.

Section H - Active Military Service
You do not need to complete parts 1 and 2 of this section if the deceased was retired at the time of death, since OPM already has this information. 1. Indicate whether the deceased performed active duty that terminated under honorable conditions in the Armed Forces or other uniformed services of the United States. Inactive service in reserve components of the uniformed service is not creditable for retirement purposes. Service in the National Guard is not usually considered active Federal military service except when ordered to active duty in the service of the United States and during an initial (3 months or longer) training period. However,

Standard Form 2800 Revised June 2006

full-time National Guard duty is creditable, if the service interrupts creditable civilian service and is followed by reemployment (as explained in Chapter 43 of title 38) that occurs on or after August 1, 1990. If you have a copy of the deceased person's DD 214s or other discharge certificate(s) showing the dates of active duty and the deceased was an employee at the time of death, you should attach it (them) to your application. 2. Persons who performed active military service after December 31, 1956, must pay or have paid a deposit to receive credit for the military service. If the deceased was an employee at the time of death, you may pay or complete the payment of the deposit by completing the election form contained in SF 2800A, which can be obtained from the agency where the deceased was last employed. The agency can provide you with more information about this deposit. Indicate whether the deceased ever received or applied for military retired pay. If you are receiving military survivor benefits, the deceased person's military service is used for survivor purposes, subject to a reduction equal to the amount of your military survivor benefits. However, if such retired pay was awarded on account of a service-connected disability incurred in enemy combat or caused by an instrumentality of war in the line of duty during a war period, or was awarded under title 10, U.S. Code Sections 12731 through 12739, (formerly Chapter 67, title 10) (reserve retired pay at age 60 based on 20 years of active and reserve service), no such reduction is

required. You should attach a copy of your award of military survivor benefits to show that the award was based on one of the above reasons.

Section J - Certification
1. Sign your name in ink. Please note that OPM will not accept the signature of someone who has a power of attorney for the applicant named in Section B. A courtappointed fiduciary can apply on behalf of the applicant, provided a court-certified copy of the court appointment is attached to the application for death benefits. If there is no court-appointed fiduciary and the applicant is not competent, a relative or person responsible for the applicant may sign. OPM will arrange later for the appointment of a representative payee for the person named in Section B.

3.

Section K - Applicant's Checklist
Use this section of the application to ensure that all required supporting documentation is attached.

SF 2800A
If the deceased was an employee at the time of death and you are the surviving spouse or former spouse, you and the deceased person's agency should complete Standard Form 2800A, which can be obtained from the deceased person's employing agency. Instructions for completing SF 2800A are contained on the form itself.

Privacy Act Statement Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a uniquely identifiable claim file. The information may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local or other charitable or Social Security administrative agencies in order to determine benefits under their programs, to obtain information necessary for determination or continuation of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number. Failure to furnish the requested information may delay or prevent action on your application. Public Burden Statement We think this form takes an average of 45 minutes per response to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the United States Office of Personnel Management (OPM), OPM Forms Officer (3206-0156), Washington, D.C. 20415-7900. Completed application forms should not be sent to this address. The OMB Number 3206-0156, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Standard Form 2800 Revised June 2006

Application for Death Benefits
Civil Service Retirement System

Form Approved OMB No. 3206-0156

Civil Service Retirement System

Section A - Information About the Deceased
1. 3. 5. Full name of deceased (last, first, middle) Date of death (mm/dd/yyyy) (Attach a certified copy of the death certificate) List any other names the deceased used (such as maiden name or his/her middle name) 2. 4. 6. Date of birth (mm/dd/yyyy) Social Security Number CSA number (if retired)

7a. Was the deceased applying for or receiving workers' compensation from the Office of Workers' Compensation Programs 7b. OWCP claim number (OWCP), Department of Labor? No Yes 8. What was deceased person's employment status at time of death (see pamphlet entitled "Applying for Death Benefits Under the Civil Service Retirement System") Employee Complete SF 2800A, which can be obtained from the deceased person's former employing agency. 9. Name of deceased person's spouse at time of death (if not married at time of death write "none") 10a. Name of deceased person's spouses from all former marriages 10b. How did each marriage end? Divorce/annulment Death Divorce/annulment Death A court has awarded this former spouse a survivor benefit. A court has awarded this former spouse a survivor benefit. 10c. Former employee Retiree

Date each marriage ended

Section B - Information About the Applicant
1. Your full name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social Security Number

4a. Are you a citizen of the United States of America? 5. Yes No I am applying for benefits as (check all boxes that apply): Designated beneficiary (attach copy of designation, if available) Widow(er) Complete Section C below

Child (or descendant of deceased child or guardian of minor or disabled child)

6.

Parent of decedent (Each parent should complete a separate application. If one parent is deceased, attach a copy of the death certificate.) Did you cash any check(s) issued to the deceased after the date of death or did you withdraw from the deceased's savings or checking account retirement monies paid by direct deposit after the date of death? No Yes

Any uncashed checks must be returned to the Treasury. (Complete if you are the widow(er).)

Clergy/Justice of Peace Other (explain) 3a. Have you remarried after your spouse died?

3b. Date of remarriage (mm/dd/yyyy)

No Yes 4a. Have you ever applied for a survivor annuity based on the Federal service of a deceased spouse other than the one named above in Section A.1? No Go to Section E 4b. Name of deceased former spouse Yes Complete items 4b-4e below 4c. Date of birth (mm/dd/yyyy) 4e. Claim number (assigned to you by retirement system in item 4d.)

Section D - Information About the Deceased Person's Former Spouse
(Complete if you are a former spouse.)
1a. Date of marriage to the deceased (mm/dd/yyyy) 2. 3. 1b. Date of divorce or annulment from the deceased (mm/dd/yyyy)

Is there a court order awarding you any portion of the deceased person's CSRS retirement or survivor benefits? Yes, on record at OPM No Go to item 4a Yes, attached Yes Go to item 3b No Are you paying for Federal Employees Health Benefits coverage to a former employing office?

3b. Give name and address of agency where you send health benefits premiums:

4a. Have you married since your marriage to the deceased ended? No Go to item 5a Yes Go to item 4b

4b. Date of first marriage after marriage to deceased ended

5a. Have you ever applied for a survivor annuity based on the Federal service of a deceased spouse or former spouse other than the one named on page 1, Section A.1? No Go to item 6 Yes Complete items 5b-5e below 5c. Date of birth (mm/dd/yyyy) 5e. Claim number assigned to you by retirement system in item 5d.

5b. Name of deceased former spouse 5d. Name of retirement system (for example, Civil Service, Foreign Service, etc.) 6.

If you checked "Employee" in Section A.8, your former spouse performed more than 18 months of creditable civilian Federal service, you were married to the deceased for at least 9 months, and a court awarded you all or a portion of the survivor annuity, contact the deceased person's employing agency in order to complete the necessary election in Standard Form 2800A.

Section E - Information About the Deceased Person's Dependent Children
1a. Are there any unmarried dependent children as defined in the instructions? Yes 1b. Name(s) of unmarried dependent children (list in order of birth) 1c. Date of birth (mm/dd/yyyy) Complete items 1b-1f below No Go to Section F 1d. Child's relationship to deceased (child of former marriage, adopted, etc.) 1e. Age 18 1f. Child's Social or over Security Number Student Disabled

2.

Is there a child of the deceased not yet born? Yes When born, send birth certificate for child to OPM Complete items 3b-3d below 3c. Name(s) of children No Yes 3d. Custodian's Relationship to child Legal guardian Other Specify

3a. Do you (the applicant) have responsibility for all the children in Section E.1? No 3b. Name and address of person having responsibility for child

Legal guardian Other Specify

Legal guardian Other Specify

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Standard Form 2800 Revised June 2006

Section F - Information About Other Heirs
List other relatives who can inherit from the deceased as explained in the instructions. Do the best you can without delaying your application. 1. Full name of relative 2. Complete address 3. Relationship to deceased 4. Social Security Number if known

Section G - Information About the Deceased Person's Estate
1. Has an executor, administrator or other official been appointed by the court to settle the estate of the deceased? No 3. Go to item 3 below Yes Yes No 2. Full name and address of person appointed

If an executor, administrator or other official has not been court appointed, will one be appointed?

Section H - Active Military Service (Complete ONLY if you are the surviving spouse or former spouse)
Complete if deceased was an employee at time of death. Do not complete if the deceased was retired at the time of death, since OPM already has this information. 1. If the deceased performed active, honorable service in the Armed Forces or other uniformed service as described in the instructions, complete all items below and attach a copy of the discharge certificate or other certificate of active military service (if available). 1a. Branch of service 1b. Dates of active duty From To

Complete if deceased was an employee at time of death. Also, complete and attach Standard Form 2800A which can be obtained from the deceased person's employing agency. 2. If any of the above listed service was performed after 12/31/56, was a deposit made to the Retirement Fund for the service? Yes No Don't know All spouses and former spouses complete 3a-3c. 3a. Was the deceased receiving military retired pay at the time of death? 3b. Did the deceased ever waive military retired pay? 3c. Are you eligible for military survivor benefits? (Attach verification of your eligibility/ineligibility for such benefits.) Yes Yes Yes No No No Don't know Don't know

Section I - Direct Deposit
1. Public Law 104-134 requires that most Federal payments on or after July 26, 1996, be paid by direct deposit into a savings or checking account at a financial institution. However, if receiving your payment electronically would cause you a hardship because it would cost you more than receiving your payment by check or you have a disability or geographic, language or literacy barrier, you may receive your payment by check. Therefore, you must select one of the following: Please send my annuity payments directly to my checking or savings account. (Go to item 2 on page 4.) Please pay me by check. I have a hardship as described above. (Go to Section J.) My permanent payment address is outside the United States in a country not accessible via direct deposit. (Go to Section J.)

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Standard Form 2800 Revised June 2006

Section I - Direct Deposit (Continued)
2. 3. 4. Do you want to have your survivor annuity payments made to the same checking or savings account to which OPM made payments by direct deposit to the deceased before his or her death (must be an active account and you must be a co-owner)? Do you want your survivor annuity payments made to a checking or savings account to which we have not already been making payments by direct deposit? Financial institution routing number (You may obtain this number by calling your bank, credit union, or savings institution. This number is very important. We cannot pay by direct deposit without it. We suggest you call your financial institution to verify this number.) What kind of account is this? 6. Account number Checking Name and address of your financial institution Savings Yes Yes No No

5. 7.

8.

Telephone number of your financial institution (including area code)

Special note: If you prefer, you may attach a cancelled personal check that shows the information requested above, instead of filling in the requested financial institution information. If you attach your personal check, it is especially important that you contact your bank, credit union, or savings institution to confirm that the information on the check is the correct information for direct deposit. (Some institutions, especially credit unions, use different routing numbers on checks.) OPM can use this information to start paying you by direct deposit.

Section J - Certification
I hereby certify that all statements made in this application are true to the best of my knowledge and that no evidence relating to the settlement of this claim is withheld. I have read and understand all of the information provided in the instructions to this application. 1. Signature of applicant named in Section B. (Sign in ink; do not print.) 3. Daytime telephone number 4. Date (mm/dd/yyyy)

(

)

Best time to call you 2. Mailing address Warning: Any intentionally false or misleading statement or response you provide in this application is a violation of the law punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years or both. (18 USC 1001)

Note: We cannot process your application if you do not complete all of Section J.

Section K - Applicant's Checklist
Attach copies of the following documents to expedite the processing of your application. Document Title Death certificate Required in all cases. Required if you were spouse of deceased at time of death (if married more than once, provide copies of all certificates). Affidavits or other proofs of common law marriage are required. Recommended for all children for whom you are applying for benefits. Remarks Attached Yes No N/A Comments

Required if you are applying as executor or administrator of deceased person's estate.

Required for minor or disabled children who have a court-appointed fiduciary. Required for any incompetent applicant who has a fiduciary. Provide if you are applying as surviving spouse or former spouse and the deceased was an employee at time of death. Failure to attach the information may delay the processing of your claim. Required from former spouse if not already on record at OPM. Needed from other applicants if available.